Provider Demographics
NPI:1316608664
Name:MITCHELL-BRIVETT, CRYSTAL SHANATAI (LMFT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHANATAI
Last Name:MITCHELL-BRIVETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1920
Mailing Address - Country:US
Mailing Address - Phone:203-597-0643
Mailing Address - Fax:203-597-0834
Practice Address - Street 1:34 MURRAY ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1920
Practice Address - Country:US
Practice Address - Phone:203-597-0643
Practice Address - Fax:203-597-0834
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003085106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist